Colorectal cancer screening in sub-Saharan Africa
Authors: Gifty Kwakye, Charles K Dally
Journal: The Lancet Global Health (2022)

Although the incidence of colorectal cancer is believed to be rising in sub-Saharan Africa, the true values are largely unknown, with current figures extrapolated from descriptive studies done in a few countries. Without hard data, government investment to support colorectal cancer management is difficult to obtain. The degree of gevernmental support is very different from efforts for breast cancer and cervical cancer treatment, which are covered under several national health insurance plans, further increasing population demand for screening and in turn, more investment allocation.1Lussiez A Dualeh SHA Dally CK et al.Colorectal cancer screening in Ghana: physicians' practices and perceived barriers.World J Surg. 2021; 45: 390-403Crossref PubMed Scopus (4) Google Scholar In 2018, the World Bank estimated that 40% of the world's population lived below the USD$1·90 per day poverty line, with sub-Saharan Africa accounting for two thirds of the world's extreme poor population.2Schoch A Lakner C The number of poor people continues to rise in sub-Saharan Africa, despite a slow decline in the poverty rate.https://blogs.worldbank.org/opendata/number-poor-people-continues-rise-sub-saharan-africa-despite-slow-decline-poverty-rateDate: 2020Date accessed: April 15, 2022Google Scholar Most countries in Africa do not have well established health insurance systems to cover the cost of care. Because of this, most patients have to pay full price for all services, including diagnostic tests, procedures, and medications. The out-of-pocket payment for colorectal cancer screening and treatment can be very costly and unaffordable for many. For example, in Ghana, the cost of fecal occult blood test (an alternative stool-based colorectal cancer screening tool) ranges from 30 to 50 Ghana cedi (GHC).1Lussiez A Dualeh SHA Dally CK et al.Colorectal cancer screening in Ghana: physicians' practices and perceived barriers.World J Surg. 2021; 45: 390-403Crossref PubMed Scopus (4) Google Scholar The daily minimum wage is 11·92 GHC (equivalent to $2·16). Following a positive fecal occult blood test, the national guidelines recommend a colonoscopy for further evaluation. A colonoscopy costs between 300 and 1000 GHC.3Eshemokha U Cost of colonoscopy in Ghana.https://nimedhealth.com.ng/2020/11/28/cost-of-colonoscopy-in-ghana/Date: 2020Date accessed: April 15, 2022Google Scholar This does not include the cost of transportation to the testing facility, required bowel preparation, sedation if desired for the procedure, endoscopic biopsies of identified lesions, or the pathological review of any specimens removed. Should a patient eventually discover that they do have cancer, they are now faced with paying out-of-pocket for the recommended staging, cross-sectional imaging, and treatment comprising of surgical intervention or chemotherapy, in addition to the cost of hospital admission. Each of these costs is an additional economic barrier to colorectal cancer screening, which could be alleviated if screening was included under health insurance plans in sub-Saharan African countries. The importance of the work of Olusegun I Alatise and colleagues4Alatise OI Dare AJ Akinyemi PA et al.Colorectal cancer screening with fecal immunochemical testing: a community-based, cross-sectional study in average-risk individuals in Nigeria.Lancet Glob Health. 2022; 10: e1012-e1022Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar cannot be overstated. It is the first study to look at the acceptability and utility of community-based colorectal cancer screening in Nigeria using the fecal immunohistochemistry stool-based testing strategy. The study provides concrete data to encourage additional studies, while also building a case to lobby for governmental support to fund screening and treatment (eg, through expansion of health insurance plans). For global health practitioners who struggle with the tension of conducting studies without imposing undue burden on a financially challenged population, Alatise and colleagues' work offers a framework to design other population-based studies aimed at sustainable systemic change. The factor which makes their study particularly unique is the intentional effort made to include a geographically and socio-economically diverse Nigerian population. This approach recognises the diversity present within individual sub-Saharan African countries and acknowledges the possible role of social determinants of health on colorectal cancer screening within parts of the population.5Choy AM Lebwohl B Krigel A Impact of social determinants of health on colorectal cancer screening and surveillance in the COVID reopening phase.Eur J Gastroenterol Hepatol. 2022; (published online Jan 31.)https://doi.org/10.1097/MEG.0000000000002350Crossref PubMed Scopus (2) Google Scholar Through this process, they discovered that the number of positive fecal immunohistochemistry tests were lower in Lagos, an urban city, than in other regions of Nigeria. The positivity rates were 11% (51 of 455; 95% CI 10–12) in Lagos, 20% (215 of 1052; 95% CI 20–21) in Osun, and 28% (166 of 597; 95% CI 27–29) in Kwara. In their Article, Alatise and colleagues touch on the need for content-specific and context-specific tailoring of both studies and interventions. An issue to draw attention to is the issue of wholesale adoption of screening guidelines developed in high-income countries as the protocol to use in sub-Saharan Africa. The limited descriptive data we do have suggests that colorectal cancer is occurring at a much younger age in sub-Saharan Africa and at a more advanced stage, with more than 60% of patients presenting with stage 4 cancer and substantially more peritoneal metastases than those in the USA.6Asombang AW Madsen R Simuyandi M et al.Descriptive analysis of colorectal cancer in Zambia, Southern Africa using the National Cancer Disease Hospital Database.Pan Afr Med J. 2018; 30: 248Crossref PubMed Scopus (10) Google Scholar, 7Saluja S Alatise OI Adewale A et al.A comparison of colorectal cancer in Nigerian and North American patients: is the cancer biology different?.Surgery. 2014; 156: 305-310Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar Given that average life expectancy is between ages 50 and 60 years in sub-Saharan African,8The World Bank DataLife expectancy at birth, total (years)—sub-Saharan Africa.https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=ZGDate: 2020Date accessed: April 15, 2022Google Scholar setting a colorectal cancer screening age of 50–70 years as used in the USA is not realistic for countries in sub-Saharan Africa and further lends to difficulties with implementation. Successful screening programmes for any disease process must reach the entire target population, have a high level of participation, be based on a screening test that is convenient for the target population to undertake, and must also be affordable to the central funding organisation.9Institute of Medicine (US) and National Research Council (US) National Cancer Policy BoardChapter 6: Improving Participation in Cancer Screening Programs.in: Curry SJ Byers T Hewitt M Fulfilling the Potential of Cancer Prevention and Early Detection. National Academies Press (US), Washington (DC)2003Google Scholar Adherence to this fundamental principle is essential as we work alongside local collaborators to design innovative context-specific screening interventions to combat the increase of colorectal cancer in sub-Saharan Africa. We declare no competing interests. Colorectal cancer screening with fecal immunochemical testing: a community-based, cross-sectional study in average-risk individuals in NigeriaColorectal cancer screening with qualitative fecal immunochemical tests in Nigeria is feasible and acceptable to average-risk asymptomatic participants. However, the low positive predictive value for advanced neoplasia and high endoscopy burden investigating false positives suggests it might not be an appropriate screening tool in this setting. Full-Text PDF Open Access